OKOJ, Volume 11, No. 8

Fractures of the humeral shaft are common, and their incidence has increased by nearly 300% in persons older than 50 years of age as compared with patients younger than this. Most fractures of the humeral shaft can be treated nonsurgically with functional bracing, resulting in acceptable healing. However, some patients and fracture patterns are more amenable to surgical fixation. Patients who are osteoporotic at the beginning of treatment may have a diminished potential for healing, and the osteopenia resulting from immobilization of their fracture and disuse of the affected arm can magnify this disadvantage. Elderly patients often have frail skin that is more susceptible to breakdown and ulcer formation, thus making the nonsurgical management of osteoporotic fractures of the humeral shaft a less desirable option in this population. Advances in modalities and techniques of internal fixation have improved the outcomes of surgical procedures for fractures of the humeral shaft in patients with poor bone quality. This article covers traditional nonsurgical treatments and discusses recent advances in the surgical management of osteoporotic fractures of the humeral shaft, and outlines strategies for their treatment.

The combination of a longer human lifespan and an active lifestyle continuing later into life has both increased the extent of pelvic and acetabular fractures in the elderly and made their treatment more significant. The greater number of medical comorbidities in the older population, the osteopenic or osteoporotic condition of bone in much of this age group, and the frequency of concomitant hip arthrosis are all essential considerations.The weakening of bone with aging allows its fracture with forces of lower energy, results in fractures with patterns that differ from those in younger persons, including more frequent impactions of the dome of the femoral head, and makes more challenging the reduction of pelvic and acetabular fractures and maintenance of their repaired state. Although some injuries in the elderly should be treated with principles and methods similar to those used in younger patients, including anatomic restoration with rigid fixation of the acetabular articular surface and pelvic ring, most injuries of the pelvis and acetabular ring in elderly patients are unique in various ways and may require treatment through other options as well as internal fixation. This paper discusses fragility fractures of the pelvis and acetabulum, and reviews the clinical presentation, different treatment options, and surgical techniques for treating these fractures in elderly patients. Although nonsurgical care, external fixation, open reduction and internal fixation (ORIF), percutaneous/limited ORIF, acute total hip arthroplasty with or without ORIF, and delayed total hip arthroplasty have all been advocated as treatment options for such fractures, considerable debate continues to surround the indications for each of them.

Fractures of the proximal humerus are extremely common in adults older than 50 years.Osteoporosis is a common comorbidity in this patient population, particularly in women, and has important implications for the treatment of such fractures. Most osteoporotic fractures of the proximal humerus may be treated with nonsurgical management, with protocols for rehabilitation designed to promote early range of motion and gradual strengthening of the rotator cuff muscles. For displaced fractures of the proximal humerus involving two, three, or four parts, as defined by the Neer classification, surgical management may be indicated. Surgical options for treating osteoporotic fractures of the proximal humerus include the use of locking plate constructs and, for fractures in which reconstruction is not possible, hemiarthroplasty or reverse total shoulder arthroplasty. Appropriate patient selection is essential for optimizing the clinical, radiographic, and functional outcomes of treatment for these challenging fractures.

Osteoporosis is a skeletal disorder characterized by compromised bone density and quality, resulting in decreased mechanical strength and predisposing to an increased risk of fracture. Worldwide, approximately one in three women and one in five men older than 50 years will sustain a low-energy “fragility fracture” because of osteoporosis in their lifetime. According to the National Osteoporosis Foundation, osteoporosis is responsible for more than 2 million fractures and an estimated $19 billion in health care costs in the United States each year. However, the screening, diagnosis, and treatment of osteoporosis in these patients are reportedly inadequate. In this article, we discuss practical frequently asked questions regarding the development and implementation of an osteoporosis fracture clinic. The establishment of a coordinated osteoporosis fracture clinic is a proactive method for the treatment of osteoporosis and prevention of secondary fractures. Such a program requires a dedicated, multidisciplinary team of orthopaedic surgeons, medical specialists, nurses, physical and occupational therapists, and medical assistants to accomplish this goal.

This special issue of Orthopaedic Knowledge Online Journal focuses on the problems associated with osteofixation of fractures in patients with osteoporosis. Part 1 of this special issue focuses on current techniques and approaches for fixation of osteoporotic humeral and pelvic/acetabular fractures, with part 2 (scheduled for later this year) dedicated to osteoporotic femoral and fibular fractures.

Subspecialty:

Trauma

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